I had the opportunity to collaborate with Mark Denesha PT, DPT and Brett Kestenbaum PT, DPT on this article with myself taking the perspective of strength coach, and Mark and Brett providing me with insights into the education and knowledge base of physical therapists. We tackled the subjects of training and rehabilitation philosophy. When I spoke with Mark and Brett about the strength training framework I use training world class athletes they agreed that the same principles would apply to physical therapy patients”
This article is meant to further the conversation and collaboration between strength trainers and physical therapists.
Most everyone will agree on the merits of building strength. Whether our experience is with the rehabilitation of patients or the development of a general strength program for collegiate athletes as mine is, the details of how to progressively build strength must be intelligently discussed and firmly understood.
My hope is to share some basic concepts of programming that are seen in all kinds of training cycles and periodization models that a strength coach would use in training athletes. I think that specific strength training concepts can be highly practical for the rehab professional as the ideas and models can be scaled down to fit the needs of our patients.
This article will teach you the basic principles of strength training needed to become a rockstar practitioner. If you learn, practice, and master the principles presented in this article I promise you will see improvements in the results you achieve for your patients.
What strength training is in a nutshell.
Before we can discuss the methods on how to build strength and organize training we need to understand what it is we’re doing across different populations. Whether we work with patients rehabilitating an injury or athletes concerned with performance, our intention is to ensure they have enough stability to hold the basic positions we’re asking of them and that they have reserves of strength to function well under external loads or different stresses. Often times a stronger individual is a more resilient individual provided they also have normal levels of mobility and conditioning.
Why work in a strength training framework?
Now that we have a basic understand of what we are doing we can turn our attention to "why". As Mark and Brett said during our conversation, "as rehabilitation specialists we specialize in rehab! It sounds kind of obvious, but sometimes, as a whole, we think this translates to specialists in everything physical. Do we have the opportunity to be the best, most educated strength and conditioning specialists on the planet? Absolutely! Our understanding of human function is unparalleled. We have spent thousands of hours curating our knowledge. We have the foundational skills to master any art of function and movement, but to get there we must recognize our current state and shortcomings and continue our studies to learn, develop, and grow."
Increasing limit strength in an individual, especially in a moderate to highly trained one, requires structured training. A model of progression needs to be implemented and followed, or results will be slow or non-existent. Models of strength training can also be extended to and modified for an untrained individual completing the rehabilitation process. If a patient has progressed to the point where greater stresses to and around the injured area are tolerable, but that patient is not given a well-planned exercise progression that presents a stimulating overload to follow, what good will the process actually do him or her? Strength training progressions for a patient will look much different from one prescribed for a competitive athlete, but the principles will be the same. A patient nearing the end of the rehabilitative process, however, could do well to have a routine that progressed either with increased loading and/or complexity of movement.
Ideas and terms behind organized training.
Terms such as training cycles, blocks, and phases of training programs often make some eyes glaze over. But what’s worse is that many of these terms and concepts are horribly misunderstood or labeled inaccurately. It’s important that everyone understand how these terms are defined, and what the definitions mean.
When referring to cycles of training we’re generally referring to specific mesocycles which are traditionally defined as three to six weeks of structured training sessions. Microcycles are the individual training weeks making up the mesocycle, while a macrocycle usually refers to a calendar year of training that includes many mesocycles. Within each mesocycle, you have phases focused on either accumulation - where volume, load or both increases over time, or de-load - where volume, load, or both are decreased or managed with the intent of reducing fatigue.
Consecutive mesocycles make up larger blocks of training. These training blocks have been defined as “summated mesocycles.” Mesocycles are grouped together to accomplish the training focus of this bigger block of time. Think long term goals vs short term goals.
The reason for focused training blocks.
The obvious question is why we even need to arrange training in focused training blocks. The practice of structuring training into phases has traditionally been used by strength coaches to bring out the most favorable training responses in elite athletes. But this is not just tradition. There’s also quite a bit of scientific evidence to support its validity.
There are three basic types of training blocks. They are hypertrophy blocks, strength blocks (sometimes divided into general strength and specific or special strength blocks) and peaking blocks. It’s pretty obvious by the labeling that each block is a focused effort to train and bring about positive adaptation in just one or two physical capacities.
We understand that the body has the ability to adapt to a limited set of qualities at any given time. If one quality is being developed but a new stimulus is introduced, the body will gradually give up the first adaptation to cope with the new stimulus. We also know that if we are exposed to a stimulus consistently and in sufficient amounts, the better and more lasting the adaptations and development of a specific quality (hypertrophy, strength etc...) will be. For example, if a person does one week of high repetition/high volume training to increase hypertrophy and work capacity, but then immediately switches to low repetition high intensity (load) training to increase limit strength capacity the very next week, he or she will not retain the adaptations from the first week of training (if any had occurred in the first place at all). The athlete clearly was not exposed to hypertrophy training long enough and in great enough amounts to create any lasting change.
A planned block of training where a particular attribute is trained for a prolonged period of time followed by another block of different emphasis that can make use of the positive adaptations of the previous block ensuring more favorable and lasting adaptations. An example of this would be performing hypertrophy training for four to six weeks, followed by a strength block where moderate volumes are done at increasing loads for three to five weeks, finally followed by a peaking block where limit levels of strength are allowed to be tested with one to three reps at 90% or above 1 rep-max. The longer and more focused blocks will allow time for not only capacities to be developed adequately but also for them to be retained as training moves into the next phase.
Managing the phases to manage stress.
When planning training, the strength coach is basically trying to manage stress to bring about the most positive effects through planning accumulation and de-load phases or training sessions.
Remember, we discussed two phases above; accumulation and de-load. Accumulation is when volume, load, or both increase, and de-load is where volume, load, or both decreased to reduce fatigue. The duration and frequency of these phases are largely dependent on training history, individual difference, and goals. Traditionally, accumulation phases will last anywhere between three and six weeks followed by a de-load phase of one to two weeks. The de-load is intended to reduce stress and so reduce fatigue allowing you to recover without losing the gain in whatever attribute (strength, hypertrophy, endurance etc...) was trained.
Although phases are traditionally set up like this, de-loads can occur every other week or within a training week in the form of a light session intended to reduce fatigue. You will need to calculate the total volume of the training program to make an educated guess on how to reduce fatigue while increasing or retaining fitness qualities built up in the accumulation phase. You will get better and better at this with practice, so don't worry if you don't nail it on your first attempt. Like a scientist, you need to make the best-educated guess you can and adapt your style based on measured results.
Scaling to more general use for the rehab specialist.
At this point, you have a great foundational knowledge of how strength training works. The beauty of a framework is that it can be applied in a variety of situations. Some of the ideas you have been introduced to who have been used by strength coaches to increase performance in their athletes can be regressed, adopted, and tweaked for rehabilitation professionals who have the freedom to work with their patients for an adequate amount of time.
To adapt this strength training framework to your patients, start with the goal in mind: Think of what you’re trying to accomplish with the rehabilitation exercise or drills you are providing. If patients need to improve tissue quality, develop stability, or re-build a base level of strength, there must be an overload component. This means the exercise plan needs to include how the exercise or drill will progress in difficulty, complexity, or volume. Overload should be planned in a systematic progressive manner before being implemented.
Create blocks or cycles in the plan: The length of the cycle is irrelevant. A cycle of training could be one week or one day in the rehabilitation setting. But each cycle should have its own focused purpose. There’s probably no reason to use traditional sports science hypertrophy, strength, and peaking cycles. However, you could plan out cycles to address joint integrity, the complexity of training, or increased total volume.
Congratulations! You are now a rockstar when it comes to strength training. Well maybe not, but at least you have a framework - a foundation of principles to build off of. I encourage each and every one of you who is serious about their craft to dive deeper into these topics and continue to build on your foundation of knowledge. You will be doing yourself and your patients a service!